Provider Demographics
NPI:1679572804
Name:SANTA ROSA FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:SANTA ROSA FAMILY HEALTH CENTER
Other - Org Name:SANTA ROSA FAMILY PRACTICE RESIDENCY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRISCUOLOHIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-703-9045
Mailing Address - Street 1:11130 CHRISTUS HLS
Mailing Address - Street 2:MEDICAL PLAZA 3, 3RD FL
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-3585
Mailing Address - Country:US
Mailing Address - Phone:210-703-9001
Mailing Address - Fax:210-703-9155
Practice Address - Street 1:11130 CHRISTUS HLS
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3585
Practice Address - Country:US
Practice Address - Phone:210-703-9001
Practice Address - Fax:210-703-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0803595-02OtherCIDC GROUP NUMBER
TX0803595-01Medicaid
TX0803595-03OtherEPSDT FACILITY NUMBER
TX0031AZMedicare PIN